NURSING 3210 Exit HESI with Answers with Correct solutions

Leadership and Management • Legal Aspects of Nursing o Often an NCLEX-RN question asks who should explain a surgical procedure to the client. The answer is the health care provider. Remember that it is the nurse’s responsibility to be sure that the operative permit is signed and is on the chart. It is not the nurse’s responsibility to explain the procedure to the client. o Often questions are asked regarding the Good Samaritan Act, which is the means of protecting a nurse when she or he is performing emergency care. ▪ Good Samaritan Act: Protects health practitioners against malpractice claims for care provided in emergency situations (e.g., the nurse gives aid at the scene to an automobile accident victim). o If the nurse carries out a health care provider’s prescription for which he or she is not prepared and does not inform the health care provider of his or her lack of preparation, the nurse is solely liable for any damages. ▪ If the nurse informs the health care provider of his or her lack of preparation in carrying out a prescription and carries out the prescription anyway, the nurse and the health care provider are liable for any damages. o Assignments are often tested on the NCLEX-RN. The Nurse Practice Acts of each state governs policies related to making assignments. Usually, when determining who should be assigned to do a sterile dressing change, for example, a licensed nurse should be chosen—that is, an RN or licensed practical nurse (LPN) that has been checked off on this procedure. o Restraints of any kind may constitute false imprisonment. Freedom from unlawful restraint is a basic human right and is protected by law. ▪ Apply restraints properly; check restraints frequently to see that they are not causing injury and record such monitoring; remove restraints as soon as possible; use restraints only as a last resort o A patient must give written consent before health care providers can use or disclose personal health information; health care providers must give patients notice about providers’ responsibilities regarding patient confidentiality; patients must have access to their medical records; providers who restrict access must explain why and must offer patients a description of the complaint process; patients have the right to request that changes be made in their medical records to correct inaccuracies; health care providers must follow specific tracking procedures for any disclosures made that ensure accountability for maintenance of patient confidentiality; patients have the right to request that health care providers restrict the use and disclosure of their personal health information, though the provider may decline to do so. • Leadership and Management o Assertive communication starts with “I need” rather than with “You must.” o Motivation comes from within an individual. A nurse leader can provide an environment that will promote motivation through positive feedback, respect, and seeking input. Look for responses that demonstrate these behaviors. o Effective leadership involves assertive management skills (i.e. democratic/participative). Look for responses that demonstrate that the nurse is using assertive communication skills. o Delegating to the right person requires that the nurse be aware of the qualifications of the delegator: appropriate education, training, skills, experience, and demonstrated and documented competence. ▪ Five Rights of Delegation (as defined by the National Council of State Boards of Nursing) • Right task: Is this a task that can be delegated by a nurse? • Right circumstance: Considering the setting and available resources, should delegation take place? • Right person: Is the task being delegated by the right person to the right person? • Right direction/communication: Is the nurse providing a clear, concise description of the task, including limits and expectations? • Right supervision: Once the task has been delegated, is appropriate supervision maintained. ▪ UAPs generally do not perform invasive or sterile procedures. ▪ The RN is accountable for adhering to the three basic aspects of supervision when delegating to other health care personnel, such as LPNs, graduate nurses, inexperienced nurses, student nurses, and UAPs. ▪ Remember the nursing process: Assessments, analysis, diagnosis, planning, and evaluation (any activity requiring nursing judgment) may not be delegated to UAP. Delegated activities fall within the implementation phase of the nursing process. ▪ Priorities often center on which client should be assessed first by the nurse. Ask yourself: Which client is the most critically ill? Which client is most likely to experience a significant change in condition? Which client requires assessment by an RN? ▪ Delegation is as follows: • Inserting a Foley catheter is a sterile invasive procedure and should not be delegated to a UAP • Measuring and recording intake and output falls within the implementation phase of the nursing process and does not require nursing judgment. However, evaluation of the intake and output (I&O) must be done by the nurse. • Client teaching requires the abilities of a nurse and should not be delegated. The UAP may be instructed to report anything unusual that is observed and any symptoms reported by the client, but this does not replace assessment by the nurse. • Assessment must be performed by the nurse and should not be delegated. The UAP may be instructed to report anything unusual that is observed, or any symptoms reported by the client, but this does not replace assessment by the nurse. o The nurse manager must analyze all the desired outcomes involved when assigning rooms for clients or assigning client care responsibilities. A client with an infection should not be assigned to share a room with a surgical or immunocompromised client. A nurse’s client care management should be based on the nurse’s abilities, the individual client’s needs, and the needs of the entire group of assigned clients. Safety and infection control are high priorities. o Change causes anxiety. An effective nurse change agent uses problem-solving skills to recognize factors such as anxiety that contribute to resistance to change and uses decision-making and interpersonal skills to overcome that resistance. Interventions that demonstrate these skills include seeking input, showing respect, valuing opinions, and building trust. • Disaster Nursing o It is important to remember that in disaster and bioterrorism management, the nurse must consider both the individual and the community. Advanced Clinical Concepts • Respiratory Failure o ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. Clients are critically ill and are managed in an intensive care setting. The mortality rate is high (50%). o Interventions to prevent complications of clients on mechanical ventilation with ARDS: ▪ Elevate head of bed (HOB) to at least 30 degrees. ▪ Assist with daily awakening (“sedation vacation”). ▪ Implement a comprehensive oral hygiene program. ▪ Implement a comprehensive mobilization program. o Suction only when secretions are present. o Before drawing a sample for ABGs from the radial artery, perform the Allen test to assess collateral circulation. ▪ Make the client’s hand blanch by obliterating both the radial and the ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be seen immediately. ▪ The Allen test is then positive, and the radial artery can be used for puncture. If the Allen test is negative, repeat on the other arm. ▪ If this test is also negative, seek another site for arterial puncture. ▪ The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture. o Cardinal signs of Acute Respiratory Failure in children are Restlessness, Tachypnea, Tachycardia, and Diaphoresis. o PCO2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. o A child in severe distress should be on 100% O2. • Shock and DIC o Early signs of shock are agitation and restlessness resulting from cerebral hypoxia. o Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extravascular spaces, further reducing cardiac output. o A vicious circle of decreased perfusion to all cellular level activities ensues. All organs are damaged, and if perfusion problems persist, the damage can be permanent. o All types of shock can lead to systemic inflammatory response syndrome (SIRS) and result in multiple organ dysfunction syndrome (MODS). o If cardiogenic shock exists in the presence of pulmonary edema (i.e., from pump failure), position client to reduce venous return (High Fowler position with legs down) to decrease further venous return to the left ventricle. o All vasopressor and vasodilator drugs are potent and dangerous and require that the client be titrated prudently. o You are caring for a woman who was in a severe automobile accident several days earlier. She has several fractures and internal injuries. The exploratory laparotomy was successful in controlling the bleeding. However, today you find that this client is bleeding from her incision, is short of breath, and has a weak, thready pulse, cold and clammy skin, and hematuria. ▪ What do you think is wrong with the client, and what would you expect to do about it? • These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the formation of thrombin (Coumadin does not do this). However, the client described is already past the coagulation phase and into the hemorrhagic phase. Her care would include administration of clotting factors, along with palliative treatment of the symptoms as they arise. (Her prognosis is poor.) • Resuscitation o NCLEX-RN® questions on cardiopulmonary resuscitation (CPR) often deal with prioritization of actions. ▪ Question: What actions are required for each of the following situations? • A 24-year-old motorcycle accident victim with a ruptured artery of the leg who is pulseless and apneic • A 36-year-old first-time pregnant woman who arrests during labor • A 17-year-old with no pulse or respirations who is trapped in an overturned car that is starting to burn • A 40-year-old businessman who arrests 2 days after a cervical laminectomy o When to seek emergency medical services (EMS): ▪ The American Heart Association recommends that those with known angina pectoris activate an emergency medical system if chest pain does NOT go away immediately with rest or is NOT relieved in 5 minutes after taking nitroglycerin or if additional symptoms such as nausea and sweating are also present with the chest pain. ▪ A person with previously unrecognized coronary disease experiencing chest pain persisting for 2 minutes or longer should seek emergency medical treatment. o Initiate CPR with BLS guidelines immediately; then move on to advanced cardiac life support (ACLS) guidelines. o When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will correct arterial, venous, and tissue acidosis. ▪ Bicarbonate may exacerbate acidosis by producing CO2. ACLS guidelines recommend that bicarbonate not be used unless hyperkalemia, tricyclic antidepressant overdose, or pre- existing metabolic acidosis is documented. o In the pulseless arrest algorithm, the search for and treatment of possible contributing factors should include checking for hypovolemia, hypoxia, hydrogen ion acidosis, hypokalemia and hyperkalemia, hypoglycemia, hypothermia, toxins, tamponade (cardiac), tension pneumothorax, thrombosis (cardiac, pulmonary), and trauma. • Fluid and Electrolyte Balance o Changes in osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is almost entirely due to sodium. The osmolarity of intracellular fluid (ICF) is related to many particles, with potassium being the primary electrolyte. The pressures in the ECF and the ICF are almost identical. If either ECF or ICF changes in concentration, fluid shifts from the area of lesser concentration to the area of greater concentration. o Dextrose 10% is a hyperosmolar solution and should be administered IV. o Normal saline is an isotonic solution and is used for irrigations, such as bladder irrigations or IV flush lines with intermittent IV medication. o Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift fluid to intracellular or extracellular spaces. o Potassium imbalances are potentially life-threatening; they must be corrected immediately. A low magnesium level often accompanies a low K+, especially with the use of diuretics. o Fluid Volume Deficit: Dehydration ▪ Elevated blood urea nitrogen (BUN): The BUN measures the amount of urea nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidneys. ▪ Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to renal excretory function. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore, it is a better test of renal function than is the BUN. Creatinine is generally used in conjunction with the BUN test, and they are normally in a 1:20 ratio. ▪ Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the same amount of solute is present, but the amount of solvent (fluid) is decreased. Therefore, the blood can be considered “more concentrated.” ▪ Urine osmolality and specific gravity increase. o Check the IV tubing container to determine the drip factor because drip factors vary. The most common drip factors are 10, 12, 15, and 60 drops per milliliter. A microdrip = 60 drops per milliliter. o Flushing a saline lock efficiently requires approximately 1.5 times the amount of fluid the tubing will hold. Remember to use sterile technique to prevent complications, such as infiltration, emboli, and infection. o The acronym ROME can help you remember: respiratory, opposite, metabolic, equal. • Electrocardiogram (ECG/EKG) o Review the order of blood flow through the heart: ▪ Unoxygenated blood flows from the superior and inferior vena cava into the right atrium, then to the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for oxygenation. The pulmonary vein delivers oxygenated blood back to the left atrium, then to the left ventricle (largest, strongest chamber), and out the aorta. o Review the three structures that control the one-way flow of blood through the heart: ▪ Atrioventricular valves • Tricuspid (right side) • Mitral (left side) ▪ Semilunar valves • Pulmonic (in pulmonary artery) • Aortic (in aorta) ▪ Chordae tendineae • Papillary muscles o The T wave represents repolarization of the ventricle, so this is a critical time in the heartbeat. This action represents a resting and regrouping stage so that the next heartbeat can occur. If defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia. (NO DEFIBRILLATION DURING T-WAVE) o Methods of Estimating Heart Rate Using an Electrocardiogram Tracing ▪ Measure the interval between consecutive QRS complexes, determine the number of small squares, and divide 1500 by that number. This method is used only when the heart rhythm is regular. ▪ Measure the interval between consecutive QRS complexes, determine the number of large squares, and divide 300 by that number. This method is used only when the heart rhythm is regular. ▪ Determine the number of RR intervals within 6 seconds and multiply by 10. The ECG paper is conveniently marked at the top with slashes that represent 3-second intervals. This method can be used when the rhythm is irregular. If the rhythm is extremely irregular, an interval of 30 to 60 seconds should be used. ▪ Count the number of big blocks between the same point in any two successive QRS complexes (usually R wave to R wave) and divide into 300 because there are 300 big blocks in 1 minute. It is easiest to use a QRS that falls on a dark line. If little blocks are left over when counting big blocks, count each little block as 0.2, add this to the number of big blocks, and then divide by 300. ▪ The memory method relies on memorization of the following sequence: 300, 150, 100, 75, 60, 50, 43, 37, 33, and 30. Find a QRS complex that falls on the dark line representing 0.2 second or a big block, and count backward to the next QRS complex. Each dark line is a memorized number. This is the method most widely used in hospitals for calculating heart rates for regular rhythms. o Observe the client for tolerance of the current rhythm. This information is the most important data the nurse can collect on a client with an arrhythmia. o NCLEX-RN questions are likely to relate to early recognition of abnormalities and associated nursing actions. Remember to monitor the client as well as the machine! If the ECG monitor shows a severe dysrhythmia but the client is sitting up quietly watching television without any sign of distress, assess to determine if the leads are attached properly. • Perioperative Care o Marking the operative site is required for procedures involving right/left distinctions, multiple structures (fingers, toes), and levels (spinal procedures). Site marking should be done with the involvement of the client. o Wound dehiscence is separation of the wound edges; it is more likely to occur with vertical incisions. It usually occurs after the early postoperative period, when the client’s own granulation tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus. o NCLEX-RN items may focus on the nurse’s role in terms of the entire perioperative process. ▪ Example: A 43-year-old mother of two teenage daughters enters the hospital to have her gallbladder removed in a same-day surgery using an endoscope instead of an incision. What nursing needs will dominate each phase of her short hospital stay? • Preparation phase: education about postoperative care, including NPO, assistance with meeting family needs • Operative phase: assessment, management of the operative suite • Postanesthesia phase: pain management, postanesthesia precautions • Postoperative phase: prevention of complications, assessment for pain management, and teaching about dietary restrictions and activity levels o NCLEX-RN items may focus on delivery of safe effective care. ▪ Time Out, Surgical Care Improvement Project (SCIP) protocol implementation, and Hand-Off communication are all best practices implemented to prevent serious medical error during the perioperative period. • Time Out occurs before making the incision and the entire surgical team pauses as the surgical site listed on the consent is read aloud. The entire team confirms that this information is correct. • SCIP protocols are best practices for safety and quality that are implemented during the preoperative period and followed up on during the postoperative period. The focus of the SCIP protocol is on prevention of infection, prevention of serious cardiac events, and prevention of venous thromboembolism. • The Hand-Off communication is the transfer of relevant patient information during the perioperative period, which is standardized and must include an opportunity to ask and to respond to questions. • HIV Infection o HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to non- pregnant caregivers that is not related to a break in standard precautions (e.g., needle sticks). o Standard Precautions ▪ Wash hands, even if gloves have been worn to give care. ▪ Wear exam gloves for touching blood or body fluids or any non-intact body surface. ▪ Wear gowns during any procedure that might generate splashes (e.g., changing clients with diarrhea). ▪ Use masks and eye protection during activity that might disperse droplets (e.g., suctioning). ▪ Do not recap needles; dispose of in puncture-resistant containers. ▪ Use mouthpiece for resuscitation efforts. o Caregivers who are pregnant may choose not to care for a client with cytomegalovirus (CMV). o Pediatric HIV is often evidenced by lymphoid interstitial pneumonitis, pulmonary lymphoid hyperplasia, and opportunistic infections. o The focus of NCLEX-RN questions is likely to be assessment of early signs of the disease and management of complications associated with HIV. • Pain o For narcotic-induced respiratory depression, naloxone (Narcan) may be administered as prescribed by the health care provider. o Use noninvasive methods for pain management when possible: ▪ Relaxation exercises ▪ Distraction ▪ Imagery ▪ Biofeedback ▪ Interpersonal skills ▪ Physical care: altering positions, touch, hot and cold applications o Narcotic analgesics are preferred for pain relief because they bind to the various opiate receptor sites in the CNS. Morphine is often the preferred narcotic (remember, it causes respiratory depression). Another agonist is methadone. o Narcotic antagonists block the attachment of narcotics such as naloxone (Narcan) to the receptors. Once Narcan has been given, additional narcotics cannot be given until the Narcan effects have passed. • Death and Grief o Do not take away the coping style used in a crisis state. o Denial is a very useful and needed tool for some at the initial stage. Support, do not challenge, unless it hinders or blocks treatment, endangering the patient Medical-Surgical • Respiratory o Fever can cause dehydration because of excessive fluid loss due to diaphoresis. Increased temperature also increases metabolism and the demand for O2. o Clients at High Risk for Pneumonia ▪ Altered level of consciousness ▪ Depressed or absent gag and cough reflexes ▪ Susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals ▪ Brain injury ▪ Drug overdose ▪ Stroke victims ▪ Immunocompromised o Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. o Hydration ▪ Thins out the mucus trapped in the bronchioles and alveoli, facilitating expectoration ▪ Is essential for client experiencing fever ▪ Is important because 300 to 400 mL of fluid is lost daily by the lungs through evaporation o Irritability and restlessness are early signs of cerebral hypoxia; the client’s brain is not receiving enough O2. o Pneumonia Preventives ▪ Older adults: Flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); no smoking ▪ Immunosuppressed and debilitated persons: Flu shots, pneumonia immunizations, infection avoidance, sensible nutrition, adequate intake, balance of rest and activity ▪ Comatose and immobile persons: Elevation of head of bed to feed and for 1 hour after feeding; frequently turning ▪ Patients with functional or anatomic asplenia: Flu and pneumonia immunizations o Exposure to tobacco smoke is the primary cause of COPD in the United States. o Compensation occurs over time in clients with chronic lung disease, and ABGs are altered. o As COPD worsens, the amount of O2 in the blood decreases (hypoxemia) and the amount of carbon dioxide (CO2) in the blood increases (hypercapnia), causing chronic respiratory acidosis (increased arterial carbon dioxide [Paco2]), which results in metabolic alkalosis (increased arterial bicarbonate) as compensation. o Not all clients with COPD are CO2 retainers, even when hypoxemia is present, because CO2 diffuses more easily across lung membranes than O2. o In advanced emphysema, due to the alveoli being affected, hypercarbia is a problem, rather than in bronchitis, where the airways are affected. o It is imperative that baseline data be obtained for the client. o Productive cough and comfort can be facilitated by semi-Fowler or high-Fowler position, which lessens pressure on the diaphragm by abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits full lung expansion. o Normal ABG Values ▪ pH: 7.35 to 7.45 ▪ PCO2: 35-45 mm Hg ▪ PO2: 80-100 mm Hg ▪ HCO3-: 21-28 mEq/L o Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. The person works harder to breathe, but the amount of O2 taken in is adequate to oxygenate the tissues. o Blue bloater: Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (cor pulmonale). o Cells of the body depend on O2 to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill (<3 seconds). A chronic sign is clubbing of the fingernails, and a late sign is clubbing of the fingers. o Nursing Skills: Respiratory Client ▪ Suctioning (Tracheal) • Suction when adventitious breath sounds are heard, when secretions are present at endotracheal tube, and when gurgling sounds are noted. • Use aseptic/sterile technique throughout procedure. • Wear mask and goggles. • Advance catheter until resistance is felt. • Apply suction only when withdrawing catheter (gently rotate catheter when withdrawing). • Never suction for more than 10 to 15 seconds, and pass the catheter only three or fewer times. • Oxygenate with 100% O2 for 1 to 2 minutes before and after suctioning to prevent hypoxia. ▪ Ventilator Setting Maintenance • Verify that alarms are on. • Maintain settings and check often to ensure that they are specifically set as prescribed by health care provider. • Verify functioning of ventilator at least every 4 hours. ▪ Oxygen Administration • Nasal cannula: low O2 flow for low O2 concentrations (good for COPD) • Simple face mask: low flow, but effectively delivers high O2 concentrations; cannot deliver <40% O2 • Non-rebreather mask: low flow, but delivers highest O2 concentrations (60% to 90%) • Partial rebreather mask: low-flow O2 reservoir bag attached; can deliver high O2 concentrations • Venturi mask: high-flow system; can deliver exact O2 concentration ▪ Pulse Oximetry • Easy measurement of O2 saturation • Should be >90%, ideally above 95% • Noninvasive, fastens to finger, toe, or earlobe • No nail polish • Must have good peripheral perfusion to be accurate ▪ Tracheostomy Care • Aseptic technique (remove inner cannula only from stoma) • Clean nondisposable inner cannula with H2O2; rinse with sterile saline • 4 × 4 gauze dressing is butterfly-folded ▪ Respiratory Isolation Technique • Mask is required for anyone entering room. • Private room is required with negative air pressure. • Client must wear mask if leaving room. ▪ Proper Use of an Inhaler • Have client exhale completely. • Grip mouthpiece (in mouth) only if client has a spacer; otherwise, keep the mouth open to bring in volume of air with misted medication. While inhaling slowly, push down firmly on the inhaler to release the medication. • Use bronchodilator inhaler before steroid inhaler. • Wait at least 1 minute between puffs (inhaled doses). • After steroid inhaler use, patient must perform oral care to prevent fungal infections. o Health Promotion ▪ Eating consumes energy needed for breathing. Offer mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed. ▪ Prevent secondary infections; avoid crowds, contact with persons who have infectious diseases, and respiratory irritants (tobacco smoke). ▪ Teach client to report any change in characteristics of sputum. ▪ Encourage client to hydrate well (3 L/day) and decrease caffeine due to diuretic effect. ▪ Obtain immunizations when needed (flu and pneumonia). o When asked to prioritize nursing actions, use the ABC rule: ▪ Airway first ▪ Then breathing ▪ Then circulation ▪ **In CPR circumstances, follow the CAB guidelines. o Look and listen! If breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not occurring. o The key to respiratory status is assessment of breath sounds as well as visualization of the client. Breath sounds are better described, not named; e.g., sounds should be described as crackles, wheezes, or high-pitched whistling sounds rather than rales, rhonchi, etc., which may not mean the same thing to each clinical professional. o Watch for NCLEX-RN® questions that deal with O2 delivery. In adults, O2 must bubble through some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification. o With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black and may appear patchy. o Tracheostomy care involves cleaning the inner cannula, suctioning, and applying clean dressings. o Air entering the lungs is humidified along the nasobronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty. o A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (first 24 hours). o Fear of choking is very real for laryngectomy clients. They cannot cough as they could earlier because the glottis is gone. Teach the glottal stop technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube). o Tuberculosis (TB) Skin Test ▪ A positive TB skin test in a healthy client is exhibited by an induration 10 mm or greater in diameter 48 to 72 hours after the skin test. ▪ Anyone who has received a bacillus Calmette-Guérin (BCG) vaccine will have a positive skin test and must be evaluated with an initial chest radiograph. A health history with signs and symptoms form may be filled out annually until signs and symptoms arise; then another radiograph is required. Chest x-rays are required on new employment; employer may require an x-ray every 5 years. o Teaching is very important with the client with TB. Drug therapy is usually long term (6 months or longer). It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating the drug therapy can result in a public health hazard. ▪ Teaching Points • Rifampin: Reduces effectiveness of oral contraceptives; client should use other birth control methods during treatment; gives body fluids orange tinge; stains soft contact lenses • Isoniazid (INH): Increased phenytoin (Dilantin) levels • Ethambutol: Vision check before starting therapy and monthly thereafter; may have to take for 1 to 2 years • Teach rationale for combination drug therapy to increase compliance. Resistance develops more slowly if several anti-TB drugs given, instead of just one drug at a time. o Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal cavity, where the lung used to be, fills up with fluid. This fluid helps to prevent the shift of the remaining chest organs to fill the empty space. o Chest Tubes ▪ If the chest tube becomes disconnected, do not clamp! Immediately place the end of the tube in a container of sterile saline or water until a new drainage system can be connected. ▪ If the chest tube is accidentally removed from the client, the nurse should cover with a dry sterile dressing. If an air leak is noted, tape the dressing on three sides only; this allows air to escape and prevents the formation of a tension pneumothorax. Notify the health care provider. ▪ Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact; they should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s position, because expanding lung tissue may be occluding the tube opening. Remember, when external suction is applied, the fluctuations cease. o Various pathophysiologic conditions can be related to the nursing diagnosis Ineffective breathing patterns. ▪ Inability of air sacs to fill and empty properly (emphysema, cystic fibrosis) ▪ Obstruction of the air passages (carcinoma, asthma, chronic bronchitis) ▪ Accumulation of fluid in the air sacs (pneumonia) ▪ Respiratory muscle fatigue (COPD, pneumonia) • Renal o Normally, kidneys excrete approximately 1 mL of urine per kg of body weight per hour. o For adults, total daily urine output ranges between 1500 and 2000 mL depending on the amount and type of fluid intake, amount of perspiration, environmental or ambient temperature, and the presence of vomiting or diarrhea. o Electrolytes are profoundly affected by kidney problems (a favorite NCLEX-RN topic). There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are the primary extracellular ions. Potassium and phosphate are the primary intracellular ions. o In some cases, persons in ARF may not experience the oliguric phase but may progress directly to the diuretic phase, during which the urine output may be as much as 10 L per day. o Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights of all clients with renal failure; obtain weight on the same scale at the same time every day. o Fluid Volume Alterations ▪ Excess Fluid • Dyspnea • Tachycardia • JVD • Peripheral edema • Pulmonary edema • Weight gain ▪ Fluid-Deficient Symptoms • Decreased urine output • Reduction in body weight • Decreased skin turgor • Dry mucous membranes • Hypotension • Tachycardia • Weight loss o Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea. o Potassium has a critical safe range (3.5 to 5.0 mEq/L) because it affects the heart, and any imbalance must be corrected by medications or dietary modification. Limit high-potassium foods (bananas, orange juice, cantaloupe, strawberries, avocados, spinach, fish) and salt substitutes, which are high in potassium. o Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and serum levels may appear near normal. With excessive water retention, the sodium levels appear decreased (dilution). Limit fluid and sodium intake in ARF clients. o During oliguric phase, minimize protein breakdown and prevent rise in BUN by limiting protein intake. When the BUN and creatinine return to normal, ARF is determined to be resolved. o Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen balance occurs, causing muscle wasting. The glomerular filtration rate (GFR) is most often used as an indicator of the level of protein consumption. o The major difference between dialysate for hemodialysis and peritoneal dialysis is the amount of glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur. o Dialysis Covered by Medicare ▪ All persons in the United States are eligible for Medicare as of their first day of dialysis under special ESRD funding. ▪ Medicare card will indicate ESRD. ▪ Transplantation is covered by Medicare procedure; coverage terminates 6 months postoperative if dialysis is no longer required. o Protein intake is restricted until blood chemistry shows ability to handle the protein catabolites, urea and creatinine. Ensure high calorie intake so protein is spared for its own work; give hard candy, jelly beans, or flavored carbohydrate powders. o As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity because digitalis preparations are excreted by the kidneys. Signs of toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac dysrhythmias, and pulse <60 bpm. o The key to resolving UTIs with most antibiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics around the clock and not to skip doses so that a consistent blood level can be maintained for optimal effectiveness. o Location of the pain can help to determine the location of the stone. ▪ Flank pain usually means the stone is in the kidney or upper ureter. If the pain radiates to the abdomen or scrotum, the stone is likely to be in the ureter or bladder. ▪ Excruciating spastic-type pain is called colic. ▪ During kidney stone attacks, it is preferable to administer pain medications at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort. o Percutaneous nephrostomy: A needle or catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid that dissolves the stone or by ultrasonic sound waves (lithotripsy) that can be directed through the needle or catheter to break up the stone, which then can be eliminated through the urinary tract. o Bladder spasms frequently occur after TURP. Inform the client that the presence of the oversized balloon on the catheter (30 to 45 mL inflated) will cause a continuous feeling of needing to void. The client should not try to void around the catheter because this can precipitate bladder spasms. Medications to reduce or prevent spasms should be given. o Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP because the irrigation must be isotonic to prevent fluid and electrolyte imbalance. o Inform the client prior to discharge that some bleeding is expected after TURP. Large amounts of blood or frank bright bleeding should be reported. However, it is normal for the client to pass small amounts of blood as well as small clots during the healing process. He should rest quietly and continue drinking large amounts of fluid. • Cardiovascular o What is the relationship of the kidneys to the cardiovascular system? ▪ The kidneys filter about 1 L of blood per minute. ▪ If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output is decreased. Therefore, a decreased urinary output may be a sign of cardiac problems. ▪ When the kidneys produce and excrete 0.5 mL of urine/kg of body weight or average 30 mL/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs. o Angina is caused by myocardial ischemia. Which cardiac medications would be appropriate for acute angina? ▪ Digoxin: not appropriate; increases the strength and contractility of the heart muscle; the problem in angina is that the muscle is not receiving enough O2. Digoxin will not help. ▪ Nitroglycerin: appropriate; causes dilatation of the coronary arteries, allowing more O2 to get to the heart muscle. ▪ Atropine: not appropriate; increases heart rate by blocking vagal stimulation, which suppresses the heart rate; does not address the lack of O2 to the heart muscle. ▪ Propranolol (Inderal): not appropriate for acute angina attack; however, is appropriate for long-term management of stable angina because it acts as a beta blocker to control vasoconstriction. o Remember MONA when administering medications and treatments in the patient with myocardial infarction. MONA: morphine, oxygen, nitroglycerin, aspirin. o Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation, weight control, and stress management can control many factors that influence the resistance blood meets as it flows from the heart. o Remember the risk factors for HTN: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives. o The number one cause of a stroke in hypertensive clients is noncompliance with medication regimen. HTN is often symptomless, and antihypertensive medications are expensive and have side effects. Studies have shown that the more clients know about their antihypertensive medications, the more likely they are to take them; teaching is important! o Decreased blood flow results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client realizes the damage is being done. o A client is admitted with severe chest pain and states that he feels a terrible tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm. What assessments should the nurse obtain in the first few hours? ▪ Vital signs every hour ▪ Neurologic vital signs ▪ Respiratory status ▪ Urinary output ▪ Peripheral pulses o During aortic aneurysm repair, the large arteries are clamped for a period of time, and kidney damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dL, and normal creatinine is 0.6 to 1.2 mg/dL. The ratio of BUN to creatinine is 20:1. When this ratio increases or decreases, suspect renal problems. o Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. Because the clotting mechanism is prolonged, do not cause tissue trauma, which may lead to bleeding when giving heparin subcutaneously. Do not mass